Live streaming echocardiography is an efficient tool to

DIU de pédagogie médicale
Année 2015-2016
Apport des nouveaux outils numériques en santé.
Expérience du projet ECHOES pour la formation
médicale.
Dr JM Davaine, Chirurgie vasculaire, CHU Pitié-Salpêtrière
Sommaire
I-
Introduction
II-
Article
a. Introduction
b. Matériel et méthodes
c. Résultats
III-
Références
IV-
Discussion
V-
Figures et tables
Introduction
La santé est désormais connectée. Internet apporte son lot quotidien d’innovations et a
littéralement bouleversé le monde tel que nous le connaissions il y a une vingtaine d’année.
Le domaine de la santé, malgré toutes ses spécificités, n’a pas fait exception à la règle. Notre
façon de travailler au quotidien a été transformée par les nouvelles technologies et les outils
numériques de même que notre façon de nous maintenir informés et de consommer le savoir
médical. La vague numérique continue de déferler sur notre profession. Les "GAFA"
(Google, Amazon, Facebook, Apple) vont-ils supplanter les acteurs traditionnels de la santé
comme dans d'autres secteurs ? Il paraît fondamental que nous soyons acteurs de cette
transformation.
Concernant l’enseignement, la génération d’étudiants en médecine actuelle ne consomme pas
et ne conçoit pas les outils numériques de la même façon que les générations précédentes qui
ne sont pas nées avec internet. L’enjeu pour les enseignants-chercheurs est double : tirer le
maximum du potentiel de ces nouvelles technologies dans le domaine de la santé et d’autre
part tenir compte du public à qui il est destiné.
Ce projet trouve son origine dans le monde du jeu vidéo et des « gamers . Nous nous sommes
particulièrement intéressés aux jeux vidéos en ligne et à leur système de diffusion qui a la
particularité d’être bon marché. Par ailleurs, ce projet associe la Chaîne de l’Espoir (CDE) et
le service de chirurgie vasculaire de La Pitié Salpêtrière. La CDE est une association
humanitaire dont l’objectif est d’assurer la prise en charge chirurgicale d’enfants vivants dans
des pays où ils ne peuvent pas accéder aux soins qui leurs sont nécessaires. Une partie
importante de l’activité de la CDE concerne la chirurgie cardiaque infantile. Des missions
sont réalisées dans les pays en difficulté ou bien des enfants sont accueillis en France pour
bénéficier de soins adaptés. D’autre part la CDE s’est fixée une mission d’enseignement des
personnels de soins locaux afin de tendre vers l’autonomisation de ces derniers. Le constat
récent de la CDE est sans appel. Les pays où se font les missions, au Moyen Orient ou en
Afrique sont de moins en moins accessibles pour des raisons d’actualités tristement connues
de tous. Pour ces mêmes raisons, il devient de plus en plus difficile de faire venir des enfants
et du personnel étranger pour, respectivement, les soigner et les former. Parallèlement, la
planète en général et ces pays en particulier sont de plus en plus connectés (figure 1). Fort de
ce double constat, la CDE a créé la Chaîne du savoir (CDS) qui vise à utiliser les nouvelles
technologies pour améliorer les soins prodigués à ces enfants et promouvoir l’enseignement et
l’autonomisation des personnels soignants locaux. Cette expérience a impliquée le Professeur
Daniel Sidi, cardiologue pédiatre à Necker, M Rémi Rousseau, ingénieur polytechnicien,
Mme Agathe Metel, coordinatrice du projet, le Dr Eric Cheysson, président de la CDE et chef
de service de chirurgie vasculaire à l’Hôpital de Pontoise et moi-même.
Nous rapportons ici comment nous essayons d’utiliser les nouvelles technologies numériques
pour les mettre au service de la santé à travers une expérience baptisée projet ECHOES.
L’introduction, les méthodes et les résultats sont rapportés en anglais et correspondent au
travail en cours de rédaction et que nous souhaitons soumettre très prochainement. La
discussion est en français et est orientée vers les perspectives pédagogiques de ce travail. En
effet, les applications pédagogiques plus locales nous paraissent prometteuses et nous
transposons actuellement cette expérience au sein du service de La Pitié-Salpêtrière pour y
développer un outil d’enseignement pratique en médecine vasculaire. De plus, nous y
introduisons le deuxième volet de ce projet qui est actuellement en cours. Il s’agit d’utiliser la
vidéo peropératoire comme outil pédagogique pour le chirurgien vasculaire en formation et
pour les étudiants en médecine.
Article
Title:
The ECHOES project: the use of live streaming echocardiography to share medical
knowledge and to improve screening of children for cardiac surgery: proof of concept
and preliminary experience from the french humanitarian organization La Chaîne de
l’Espoir
Introduction
The use of telemedicine has considerably developed over the last decade and fulfills the need
of rapid medical advice in various fields such as general medicine, dermatology, diabetes
mellitus (1-3). Telemedicine has also a critical potential in terms of educational purposes.
Progress of new technologies have proven useful in situation where medical advice is required
in difficult to access areas whether because they are remote (4,5) or politically dangerous.
Several attempts with encouraging results have been made in the field of echocardiography
(6) and emergency echography (7).
La Chaîne de l’Espoir (CDE) is a humanitarian organization which goal is to fight against the
injustice of birth and allow optimal treatment for children with untreatable diseases in their
country. To do so, CDE has organized either the transfer of children in France to be treated
properly and sent back to their country and family or even better, as often as possible, to
ensure that the local abilities are able to treat those children through their own medical
institutions.
In the field of cardiology, CDE has helped in the construction, equipment, and training of
medical, paramedical and administrative local people. This experience was accomplished in
several institutions like in Vietnam in the early 90th, Cambodia in the late 90th, Mozambique
and Afghanistan in the early 2000th. The CDE fosters the development of these institutions
towards self sufficiency through medico surgical missions. Currently, the CDE is present in
around 30 countries. Beside the 4 institutions aforementioned, CDE has a local desk with
either representant having knowledge in pediatric cardiology (13 countries) or a doctor
without echography (11 countries). Every year, around 800 children with heart disease are
operated on either in France (about 200) or locally, especially from congenital heart diseases.
Before 2015, we had to multiply missions to expertise patients and train cardiologists that
used to spend 1 or 2 years in France. Over the last years, the missions have become
increasingly dangerous in these countries. Access for NGO members is frequently forbidden
by the french government. As a result, the number and length of the missions are decreasing.
Moreover and for similar reasons, it is becoming much more difficult to train foreign doctors
or nurses in France.
A critical issue remains the inaccuracy of preoperative assessment.
Currently, 1 out of 10 children who were initially suggested by local physicians for a surgical
treatment are finally deemed not fit to undergo surgery. The reason lies in the lack of fullyformed personnel to thoroughly and accurately evaluate these children in the preoperative
period. As a consequence, missions cannot be prepared as effectively as necessary. Medical
device and staff cast for the missions cannot be sufficiently anticipated because of the lack of
accurate information, resulting in impossibility to perform surgeries and preventing some
children to be treated properly.
Since February 2015, we have introduced telemedicine in our practice. New technologies
represent an opportunity to improve our access to these children in need of medical care and
to share medical knowledge with local physicians. What was initially seen as an opportunity
has clearly evolved into a necessity. CDE has thus created La Chaîne du Savoir (Chain of
Knowledge, CDE) (figure 2) to tackle these issues by using the latest available technologies.
We decided to use live streaming technology applied to echocardiography to screen children
that are good candidates for heart surgery. In this project, called the ECHOES project, a very
accomplished tool has been set up to allow CDE experts, having a deep knowledge of these
countries, to supervise pediatric cardiology consultation in collaboration with local
physicians. The aim of this project is twofold: provide real time specialized advice for
patients presenting in remote hospitals and train the local medical team to reach selfsufficiency (North- South collaboration). Also, this project aims at setting up the missions, in
terms of medical devices and staff, as sharply as possible. Further, this project aims at helping
foster the development of a local network (south- south collaboration). We report our
experience with the first center in Cambodia, while two other centers have joined the program
since.
Methods
Population
All children were treated in «Le pavillon des enfants cardiaques », a center specialized in
pediatric cardiology, in Phnom Penh, Cambodia. Children presenting with cardiac
insufficiency symptoms were examined in this center. After a first local screening, children
were scheduled for a live echocardiographic session.
Live streaming sessions
Sessions took place on a weekly basis according to a predefined schedule with a number of
patients ranging from 5 to 10. Beforehand, a medical summary including local conclusions
was sent by email to a CDE expert. Before the session, children were locally examined and
an email with details of the session was sent to the CDE. The same expert supervized the
sessions in Paris along with a cardiac surgeon.The session consisted in a clinical and
echocardiographic examination ran by the referent cardiologist in Phnom Penh under the
supervision of our experts. Four physicians were available in Phnom Penh, one considered as
a senior and local expert, and the three others were in training. In Paris, our experts had on
one screen, in real time, the exact same image that was acquired by the echocardiographist in
Cambodia. On a second screen, a live image of the patient was also on display to provide
additional clinical information (figure 2). Cambodian surgeons, others physicians involved in
the care of the children, as well as fellows and trainees were also present to discuss each case
with the CDE staff. At the end of each session a decision was made as to whether the patient
should undergo surgery or should proceed with medical treatment or alternatively should
undergo further investigation.
Technical aspects
The equipment used is cheap and widely available. There are two technical aspects to be
solved to start a session: (i) getting a video feed for an echo machine to a computer and (ii)
being able to livestream the video feed to this computer.
- getting a video feed for an echo machine to a computer
Videogame Live broadcasting has become a very popular practice in the last years with the
emergence of platforms like Twitch (http://www.twitch.tv/) that allow anyone to broadcast
their videogame session. It has opened an interesting market for video capture devices used by
streamers to connect their TV screens to a computer. Those devices are inexpensive (<500$)
and performant. Ultrasound machines are almost always equipped with a video output, though
the nature of the connector varies between different machines: it can be DVI-D, S-video,
HDMI, VGA. We tested different video capture devices and had great success with two: the
Elgato Game Capture HD, because it supports retrogaming (recording videogame sessions on
old consoles), is equiped to handle a lot of different connectors but it doesn’t support all
resolutions. More recently, we also had great success with the Ephiphan AV.io capture device
which transforms the video feed from the echo machine into a virtual camera recognized by
the PC. One of our objectives in the future developments is to build a database of every
ultrasound machine available and detail the precise process and hardware to get a video feed
from them available for streaming, which will be available on the Echoes platform. Those
video capture devices have to be connected to a recent laptop or desktop computer that can
handle the live video decompression.
- being able to livestream the video feed to this computer
Being able to broadcast live is critical for the quality of the session. We benchmarked several
software solutions and ended up with the Vidyo solution, which delivers the best quality with
the lowest bandwith available. The bandwith available is indeed the critical technical issue in
the project and it has to be superior to 1Mbps to deliver a good enough quality for
interpretation. The Vidyo feed can then be embedded in a webpage with the Vidyo API or
visualized on a smartphone with the Vidyo app. An aditionnal camera connected to the
broadcasting PC allows to broadcast both the video feed for the ultrasound machine and the
videofeed from the patient. A mike and speaker are necessary. The overall aditionnal cost of
the installation was inferior to 500$: it’s the cost of the video capture device, cables and an
additional camera. The PC that serves for the broadcasting was already there.
A cost to take in consideration in some countries would be the bandwith cost, which vary a lot
from place to place.
Results
Since 2001 around 4500 procedures (catheterisms or surgical procedures) have been
organized by the CDE organization in Phnom Penh. The present echo-experience has begun
in February 2015. After 15 months (until May 2016), a total of 253 cases have been treated in
the setting of this project. A mean of 7 children were examined per session, which occurred
on a weekly basis. The mean length of a session was 41.8 min. The mean time spent with each
child was 6.5min. The mean age of the children was 4.3 years old at the time of examination.
Typical proceedings of a session has been displayed on national television and can be seen on
the following link: http://www.francetvinfo.fr/sante/soigner/medecine-humanitaire-realiserune-echographie-a-distance_1442929.html These children suffered from ventricular septal
defects in 83 cases (32.8%), tetralogy of Fallot in 78 cases (30.8%), atrial septal defects in 35
cases (13.8%), persistent ductus arteriosus in 15 cases (5.9%) and other diagnosis in 42 cases
(16.7%) (Table 1). In all cases the children examined with the CDE expert during an echosession had been previously examined by the local team. Ultimately, the sessions were
characterized by two main scenarios. Whether the diagnosis was confirmed, or in contrast
straighten up by the CDE expert. At the end of a session, the children examined were
scheduled for a surgery/ catheterism by the local team or during a foreseeable mission of the
CDE in Cambodia. Alternatively, the children could be re-scheduled for another session if
further workup was required. A total of 171 (67.6%) procedures have been performed during
this period, including surgical procedures in 146 cases (85.4%) and therapeutic catheterisms
in 25 cases (14.6%). Nine postoperative death occurred due to multiple organ failure in
intensive care unit in 4 cases, pulmonary failure in 2 cases, cardiac insufficiency in 2 cases
and from unknown cause in one case (the patient died at home after discharge) (Table 1). The
other 162 patients are alive and are still followed up by the local team and by echo-session
when necessary. As for the other patients they are not yet operated on, considered as no
indication for surgery, lost to follow up, or refused surgery, or sometimes diagnoses too late
to undergo surgery.
The first main impact of this experience that we noted is the way CDE organizes its
missions. Previously, every three or four months, a team (surgeons, pediatricians,
cardiologists, anesthetists, nurses) was sent to Cambodia with medical equipment. Human and
technical means were chosen to be as accurate as possible. The first day of the mission a large
number of children were screened in order to determine the best candidates for surgery. A lot
of children could not be treated due to late diagnosis or due to the lack of appropriate medical
equipment. Since the beginning of this experience the way the missions are set up have
dramatically evolved. Several children (around 7) are examined every week. Diagnosis are
ascertained by our experts. As a result CDE team is able to schedule the missions almost as
sharply as it would be done in one of our local hospital in current practice. Medical material
and physicians are chosen according to a pre-defined schedule. Most importantly, the delay
between a first local consultation and diagnosis has considerably diminished for the children.
The second main impact that we have noted is the benefit in terms of transfer of
knowledge. The local team is made of 1 senior cardiologist and 5 cardiologists in formation.
Every child presented during a live session were previously evaluated by the local team. This
project offered the local cardiologists a comprehensive hands-on training with strong followup with our experts. After 15 months of experience, both our experts and the local team had a
strong feeling that considerable progress had been made towards self-sufficiency. The mean
length of the sessions remained similar, but as we went on this project, more time was spent
on training and education as less time was necessary to straighten up incorrect diagnosis. It is
important to emphasize that both teams had a deep knowledge of each other through many
previous missions, which was, according to us, a key component to the success of this
experience.
Finally, this experience has proven very efficient in terms of technical success.
Provided that the two centers have a good internet connection, this protocol almost never
faced technical failure in our experience. Moreover, this good technical result was achieved at
a very affordable price (less than 500$). As a result, the CDE is currently spreading this
plateform to other countries (Mali, Afghanistan, Kenya, Senegal). A hub is being launched by
the CDE to allow access to other centers through a very straightforward process (figure 4).
Discussion
Cette experience de télé-échographie en direct est une opportunité qui s’est transformée en
une nécessité. Ce qui au départ était une tentative visant à pallier à un problème d’accès à ces
pays a finalement transformé la pratique de la CDE dans la façon de monter ses missions et de
transmettre le savoir medical aux équipes locales. Le délai d’accès des enfants à un examen
complet est raccourci. Il en découle que le délai d’accès au bon traitement est également
écourté. La qualité de l’examen est excellente: l’image du patient, le son et la capture
échographique sont d’excellente qualité. Des expériences similaires sont mise en place par la
NASA ou l’agence spatial européenne ou à distance entre centres de pointe. L’originalité de
l’approche est son faible coût, ce qui n’est pas le cas des autres programmes et de plus son
bénéfice en terme de pédagogie. Un véritable contrôle continu et une véritable formation dans
la durée est rendue possible par cette approche.
Les limites scientifiques de ce travail sont évidentes. Nous n’avons pas pu montrer de
bénéfice en terme de mortalité, de délai de prise en charge, de complications, de manière
objective. La raison est que ce travail n’était pas prévu au départ pour cela. Actuellement, la
plateforme ECHOES s’ouvre à d’autres centres (Sénégal, Mali, Afghanistan) et en parallèle
un outil de database prospective est mis en place afin d’objectiver cette activité de la manière
la plus scientifique possible.
Les applications pédagogiques locales sont certaines. Nous transposons actuellement cette
expérience au sein du service de chirurgie vasculaire de La Pitié-Salpêtrière. Tous nos
patients opérés bénéficient d’un examen écho-doppler avant leur sortie auprès des médecins
vasculaires du service. Cette équipe assure une formation en échographie vasculaire dans le
cadre d’un DIU (DU Ultrasonographie Vasculaire). Les enseignements pratiques sont
difficiles à organiser et les enseignants et enseignés se plaignent d’un manque de suivi dans le
temps. L’apprentissage de l’échographie vasculaire nécessite en effet une formation pratique
et sur le moyen voire le long terme. Nous mettons actuellement en place ce système afin de
pouvoir échanger, via la platerforme de la chaîne, avec tous les participants de ce DIU.
Beacoup d’entre eux sont praticiens (urgentistes, cardiologues, internites, médecins
vasculaires en formation, chirurgiens vasculaires) et exercent en dehors de Paris et pour bon
nombre d’entre eux dans les pays du maghreb. Ce système permettra aux volontaires de
soumettre des cas de patients en direct aux médecins réfèrents du service lors de sessions
programmées. Nous espérons un résultat similaire à celui présenté ici.
La suite de ce projet au sein de la CDS est de developer un versant chirurgical, ce qui est en
cours. Un système de capture de video a été mis au point en collaboration avec l’ingénieur
travaillant sur ce projet. Deux caméras GoPro synchronisées sont fixées sur un casque.
L’opérateur, équipé du casque, peut capter ses interventions. Des applications légères sur
smartphone permettent d’éditer facilement la vidéo. Celle-ci peut être utilisée comme une
video standard ou utilisée en réalité virtuelle en utilisant un casque type Occulus rift.
Là encore le coût est très modéré (moins de 1000 euros d’équipement). Les applications
envisagées sont: de créer une banque de vidéos chirurgicales; d’utiliser ces vidéos comme
outil de progression pour les chirurgiens en formation, comme un sportif de haut niveau
pourrait le faire. D’utiliser la réalité virtuelle pour améliorer l’expérience, en consultant le
contenu avec les yeux de l’opérateur. Ainsi, un étudiant en médecine pourrait “s’immérger”
dans une salle opératoire, un chirurgien pourrait “s’immerger” en direct et à distance dans la
vue opératoire d’un collèguee et le conseiller, le guider au cours d’une intervention. Là aussi
nous pensons que les applications Nord-Sud et locales, plus académiques, sont nombreuses.
Références
1- J Am Coll Cardiol Img 2014;7:799–803.
2- J Am Soc Echocardiogr 2013;26:221–33.
3- J Am Coll Cardiol Img 2014 ;7:810-811
4- MEDINFO 2015: eHealth-enabled Health ; 2015 : 1-61499-564-7-937
5- IEEE Communications Magazine 2006;44(4):41-8.
6- International Journal of Telemedicine and Applications 2015 ; Article ID 504015
7- Telemed J E Health. 2015 Sep 16
Figures
Figure 1 : Couverture internet prévue en Afrique sub-saharienne, projection 2019
Figure 2 : logo de la chaîne du savoir
Figure 3 : Déroulement typique d’une séance
Paris
Phnom Penh
Figure 4 : plateforme échographique en cours d’installation
Tables
Table 1
Pathologies
N (%)
Opérés
Cathétérisme
Décès
CIV
83 (32,8%)
42
1
3
T4F
78 (30,8%)
70
CIA
35 (13,8%)
9
11
PCA
15 (5,9%)
10
4
CAV
9 (3,5%)
7
APSO
4 (1,6%)
0
RM
6 (2,3%)
3
IM
4 (1,6%)
2
RA
6 (2,3%)
3
SP
6 (2,3%)
0
6
VM bio
1 (0,4%)
Mal Ebstein
2 (0,8%)
CMD
1 (0,4%)
S. Mediov
1 (0,4%)
HTAP Ir
1 (0,4%)
Sd Klippel T.
1 (0,4%)
Total
253 (100%)
146 (57,3%)
25 (9,9%)
5
1
3
9 (3,6%)